Views of a lifestyle

David Courtwright Dark Paradise : A History of Opiate Addiction in America 1982, 2001 Harvard University Press.

Caroline Jean Acker Creating the American Junkie: Addiction Research in the Classic Era of Narcotic Control 2002, Johns Hopkins University Press.

In the following review I go back and forth between Courtwright and Acker’s books, presenting information in a series of slightly different guises. I will clarify my view of these books from the vantage point of my own preferred theory of drugs policy and of the social constructs “addiction” and “junkie.” By the end, readers will realize that I have not in fact been flying off at various tangents but keeping within a single circle of inquiry, sometimes actually returning to the same spot.

The books by Courtwright (1st ed. 1982, 2nd ed. 2001) and Acker (2002) that will be discussed here were written by historians, rare birds in the field of drugs research. It is a field where you are more likely to find physicians, psychiatrists and neurologists, although sociologists have been sniffing around the area in relatively large numbers since 1945, some of them (e.g. Lindesmith, Waldorf, Gerritsen, Bergeron) throughout their careers. Acker sets out to discover how perceptions of “addiction” to drugs (in particular opiates) have changed since the mid-18th century. Courtwright is more interested in finding out how many addicts there were (he calls this “historical epidemiology”) and how US policy on these addicts developed over the years. Their accounts take us up to the 1990s.

You might have expected that the advent of sociological analysis in the 1930s would long ago have made it possible to put attachments to drugs and alcohol into some sort of social perspective. The shift from a medically-based habit of taking opiates and giving them a role in one’s life to a habit based on a new functionality (including boasting, having fun, getting stoned out of your mind, self-medication or having a brief moment of relaxation, as often as you want) is a societal development that takes place outside the field of vision of psychiatrists and police officers but can be charted by sociologists. This insight ought to result in the use of a different terminology. What psychiatrists call addiction (and see as being “possessed” by drugs, alcohol, food or whatever), sociologists might call a lifestyle. It is a lifestyle that may have consequences for your body, but that is often true of bon vivants – and it also applies to sportsmen and sportswomen, or to a devoutly religious mother who has 13 children.

Whereas Courtwright describes in detail iatrogenic and recreational use in terms of two different “types of addicts,” I would suggest that the recreational use of drugs represents a social expansion of types of behaviour, and should be described in correspondingly different terms (which would make it possible for addicts to undergo a conceptual change – as witches did, once – into ordinary human beings that look like anyone else because no one particularly notices them).

It is very clear from these books that we have a long way to go, and that the history of addiction is an important but largely undeveloped area of research into the views that we have of our humanity and individuality.

The concept of “addiction” should be seen, it seems to me, as a deeply superstitious construct forged in the 18th century, an age in which the vast majority still believed that you could be “possessed” by the devil, “bewitched” by Evil, in short that you could be taken captive by some external Force.

It is fascinating to see how religious the attitudes of psychiatrists were as they developed ways of looking at opium addiction, in the age – around the beginning of the 20th century – in which psychiatry itself was undergoing rapid development. Medical “addicts,” the first people who did not want to live without opium or morphine, could continue to use the opiate in a wholly respectable way – as long as it was prescribed by a physician, for maladies such as pain, nervous tension, or any other reason deemed to be justifiable. Their non-medical counterparts, people who could not obtain morphine on prescription under the aegis of medical opinion, were regarded as “addicts” of an entirely different kind. The intentions associated with their behaviour hence became a key distinguishing feature, even though the behaviour of the two groups was identical.

Does this attitude reveal traces of Puritan ethics and remnants of a belief in predestination? Or should it rather be seen as part of the medical profession’s struggle to monopolize the entire array of pharmaceuticals through opiates? The latter, says Acker, although she believes that other interested parties also played a role. [2]

Courtwright himself uses the term “addict” fairly non-specifically – just as people have always done in the street, ever since the late 19th century. Acker, on the other hand, asks what different observers mean when they use the word, but she doesn’t get very far with answering the question.

Acker comes closest to putting the concept of addiction in a useful perspective when she presents it as a form of deviant behaviour to which a certain cultural value is attached in part because it is linked with other deviant forms of behaviour (“vice”) like crime and prostitution. She identifies key turning-points in the development of views of drugs (especially opium, morphine and heroin) by looking at the particular links that were made – particular combinations of deviant behaviour. If addiction occurs among prostitutes, the social problems surrounding drugs and prostitution will be linked, and each strengthens the extent to which the other is defined as a problem. She comments: “Opiate addiction in the 1920s and 1930s provided a nexus around which various social reform and scientific constituencies could develop agendas, marshal and allocate resources, and advance their own work. These constituencies included social reformers, biomedical scientists, physicians, policy makers, public health officials, and enforcement officials.” (p. 96).

This conclusion, or the revelation of these social complexes, helps Acker to show that opiate addiction could not be a neutral item on a scientific agenda, but was just one emotionally charged element of an intricate complex of group and policy interests. These interests ensure that every description has some financial consequence, that every new form of drug discourse could be fatal to one or more groups. And this still holds good today, although these interests have grown exponentially because budgets are far larger, and there are far more institutions that owe their existence to the ban on the use of drugs. One example is the extraordinary expansion in the budgets for “treatment,” which has created a separate caste of high priests of addiction language.

Another big difference between now and the 1920s is that the relatively new international enmeshment created by the UN drugs conventions has elevated the constructions set up in the early twentieth century into a virtually unassailable jumble of transnational interests.[3] Strangely enough, neither Courtwright nor Acker discusses this international enmeshment in their accounts. They do show, however, that “drug research” is an integrated part of a structural complex of interests, which sustains itself invincibly in a form of mutual clientism.

In contrast to the depth of Acker’s discussions of the history of thoughts and attitudes about “addiction,” her analysis of the current situation in the United States seems meagre. At several points she welcomes the prescription of methadone for opiate users, a form of maintenance that she shows was completely expunged as a possible form of intervention in the US in the 1920s. But heroin maintenance is still taboo in the US , and she does not subject the harsh regimes in – nowadays privatised – methadone clinics to any scrutiny.

She mentions the “draconian drugs legislation” in the US , but says nothing about its impact on deprived urban ghettos. And the fact that the United States , partly through its drugs legislation and the radical exploitation of fear (not just fear of drugs but also of communists, terrorists, murderers, burglars, and the culture of the 1960s) now has the biggest gulag in the world is something we do not find out by reading Acker. [4]

Drugs legislation and the drug police (DEA) have generated an unprecedented momentum in mass transportations to the reception areas of the gulag since 1987. The corruption of sentencing and criminal law (which Americans call “sentencing reform”) means that the jail and guards businesses are booming. Why did neither Acker nor Courtwright want to write about this? Have they elected to present their criticism obliquely, through their sometimes vitriolic accounts of the past?

In any case Acker sadly provides virtually no criticism of the narcotics police or the National Institute on Drug Abuse (NIDA). All she can muster is a few jibes at the predominantly neurology-oriented types of research favoured by NIDA, the generously funded research branch of US prohibitionism. [5] On the other hand, she demonstrates her epistemological quick-wittedness with some lucid criticism of the “random” surveys in the old work of the sociologist Bingham Dai, whose influential accounts of drug use before the Second World War were based solely on the indigent inmates of prisons and clinics.

Notwithstanding the above points of criticism, Acker’s book is of great value, and much of it makes fascinating reading. It provides an elegantly panoramic view of the history of the “junkie.” In her opening sentence she asserts: “The American junkie is a product of American history.” This immediately signals the strongly sociological and historicizing tone that characterizes her work, and sets it worlds apart from the theoretical musings in psychiatric, neurological and pharmacological vein that still dominate the field. Few theorists have conducted serious research on the “junkie.” Norman Zinberg, a Boston psychiatrist and psychoanalyst who was active from the 1960s to the 1980s is to my knowledge the only writer who has tried to describe the careers of a small proportion of drug users in such a way as to make physical and mental “junkification” intelligible as a social process. This article (curiously published in a journal of child psychoanalysis) defined him as the most sociological of drug psychiatrists, a role that he retained until his death. Like Acker, he rejected an analysis of junkies that is based on brain cells or pharmaceutical agents.

What Acker tries to do is to place the new phenomenon of the “junkie” at the centre of her inquiry, but without supplying the quantity of detail that Zinberg gives us. Using a large number of sources, she reconstructs the way in which scientific and political elites have viewed the process or existence of addiction to opiates over the past hundred years. She historicizes the concept of junkies by placing the rise of their clochard-like existence in the context of the period following the prohibition of opium. She shows that medical addicts hardly if ever became “junkies,” because they were not sucked into the deadly cocktail of proletarian background, urban “vice control,” prison and clinic. Medical addicts were not deprived of the opportunities to become socially integrated. They were not robbed of, or threatened in, every conventional role, such as that of parent or employee. When the legal access to opiates was reduced further in the 1920s, this phenomenon became more marked still. Courtwright endorses this view.

In her descriptions of medical and non-medical “addicts,” Acker thus covers the same ground as David Courtwright in Dark Paradise. This latter book, which has been successful ever since its first publication, has now been followed by a second edition. It is this new edition that will be reviewed here.

Both Acker and Courtwright have studied the sources in the United States ’ superb libraries meticulously, so they are thoroughly acquainted with the lion’s den. Many of the basic principles and legal consequences of today’s drug policy – as based on the UN drug conventions – are in all but name an American institution, something that both these books clarify; for this reason alone they are indispensable. David Musto’s The American Disease. Origins of Narcotic Control (1973) is still the standard work in this field, however. Books on drugs policy that delve as far back in history as these three are immensely confusing for interested lay readers, since they only deepen the riddle of present-day drugs policy. I recall that the revelations of Musto’s book gave me a sense of returning to the age of the Spanish Inquisition, the burning of witches, or bloodletting, such is the intrusiveness of the drug control regime in our own time.

I had a similar response to the first edition of Courtwright, though less intensely, and Courtwright also struck me as less relevant. On re-reading the text exactly twenty years later, I have found myself frequently taking my hat off to his achievement. Here is a historian whose work I had initially rather disparaged because of his lack of sociological distance and imagination, but few could do what he has done: to create a list of references and to illuminate a large quantity of highly inaccessible material. The sheer time it must have taken him to trace those papers, to read the manuscripts and letters, and to scrutinize the corrections of old manuscripts in the same way that the authors themselves must have done! And the many meticulous descriptions of his material, providing plenty of points of departure for excursions that others will have to make into the outskirts of philosophy, cultural theory or sociology.

As I have already said, both Acker and Courtwright run up against the old dichotomy that is generally used in classifying types of addiction, namely between those who were “unfortunate” enough to acquire an addiction, generally through medical treatment with an opiate, and “totally degenerate” addicts, those mentally disturbed pleasure seekers who deserve nothing better than rehabilitation through detention.

Using quotations from users and reports of researchers who have interviewed users, Acker and Courtwright show how the aetiology of drug use has changed in the course of the 19th and 20th centuries. In the 19th century, opium (including its derivatives codeine and morphine) was the only active agent with which to suppress constant diarrhoea, headaches, menstrual cramps or depression. But the new medicines of the 20th century (notably aspirin!) made it possible for heroin to become a substance that could also be used to give “pleasure” or for some other purpose.

Both authors show that the moralistic attitude to opium use inherited from the United States is fairly similar (though not identical) to attitudes to alcohol. As soon as these substances are used largely in the context of fun and games in the big city (“vice”), they come to symbolize the loss of devout rural life, the primal way of life of white Christian Americans. Alcohol was already regarded as the crowning shame of workers’ misery, and the modern use of heroin by the urban proletariat was seen as more of the same. “Alcohol and drugs were also prominent features of the social scene that seemed to give rise to prostitution and syphilis” (Acker p. 27). The belief in a causal and absolute connection between substance and behaviour (as evaluated in moral terms) is inherent to all classical views of drugs and alcohol. Only seasoned sociologists can escape from this by identifying social status, urbanization and economic structure as vital ingredients of the whole. One of Acker’s strengths is her lucid explanation of this point in her history of the “junkie.”

Acker covers just as much ground as Courtwright, but her thorough sociological training enables her to do much more with her material. Although her book is not as impressive as the best products of modern drugs sociology (Reinarman and Levine’s syntheses in “Crack in America” in their anthology of the same name) this is partly because of the high level of abstraction that characterizes her work. Reinarman and Levine stay in the ghettoes and explore the astonishing hysteria about crack, which makes it easier for them to make an impression.

That drugs policy also became a function of various progressive movements in the United States at the end of the 19th century is a point that Acker rightly repeats several times. “Progressive” should be understood here in the sense of favouring state intervention to tackle social problems such as drugs or prostitution. Acker aptly illustrates the fact that the very definition of what constitutes a “social problem” is of course in itself an interesting sociological phenomenon.

As she notes concisely, “the key question was whether addiction was a disease or a vice” (p. 38). Academics tried to answer this question in their search for the right policy, and came up with mixed answers. Addiction was both disease and vice, and the crucial point was the category into which each person was predominantly classified. Selection was everything. To put it crudely, one category leads down the road to criminalization and being labelled a “junkie,” while the other leads to legal access to the chosen substance, which means being able to work, earn money, and remain within mainstream society.

An attachment to alcohol or some other substance, and not wanting to live without it, could not yet be seen, in the 19th and 20th centuries, as a lifestyle or mode of adjustment that modernity had made possible – a lifestyle with just as much right to exist as the equally new attachment to a 9-to-5 working day or the conscious decision to live, for instance, without any religious beliefs, or as an unmarried mother. [6]

Even today, we have not yet reached that point. Neither has Acker, it seems to me. Disease or vice remains the key question around which her argument revolves, although she brings out a number of authors who describe addiction (whatever that may be) as a learned lifestyle that subsequently assumes central importance in a person’s life (Becker, Goffman). But she does not describe their writings as innovative work that provides conceptual aids to help us escape from the quagmire of addiction/possession mumbo-jumbo, that deeply-entrenched heritage from the Middle Ages. Acker also displays her powerlessness in her occasional mentions of nicotine, and declines to distance herself from the official position of the Surgeon General on the addictive qualities of tobacco and nicotine. [7] She does remark, however, that “nicotine addiction” is really not so terrible, and I have a strong suspicion that this is her way of saying that the argument is full of flaws! But whether tobacco use can be understood in the pharmacocentric view of human behaviour proposed by cell biologists and pharmacologists is a question she is either unable or unwilling to ask.

The change in status that homosexuality has finally achieved in some countries – after a long and highly emotional social struggle – away from the dichotomy of disease or vice towards a lifestyle within the limits of “normality” is not a transition that Acker has achieved with the terms she chooses to employ for attachments to drugs. She does concede that many view incidental drug use as a hellgate, analogous to the Fall of Adam and Eve – drugs being the “apple” of today’s world. Alcohol has been described in similar terms, but this description has largely vanished; in most patterns of consumption, alcohol has become normal.

Courtwright’s book is primarily an attempt to reconstruct the use of opiates in the United States in the period of the political developments leading up to their prohibition. To achieve this, he presents a large number of sources and cross-validates them, ending up with an explanation of the grossly overestimated figures for opium users in the latter half of the 19th century. He starts with a chapter on the fate of opium and morphine, goes on to that of heroin, after which comes a chapter on smoked opium. For Courtwright, the substances themselves provide the classifying principle for the material he presents.

The policy fate of the diverse substances and their users’ vicissitudes are discussed at length. He is most concerned to show that the authors of reports have sometimes “manipulated or even fabricated data” (p. 9). The sources he opens up are mainly of interest to those doing research in the field. Of much wider relevance is Courtwright’s conclusion that in the period when the core concepts of American drugs policy were under construction (1910-1920), public opinion was “profoundly influenced by inaccurate and even falsified data” (p. 33).

He argues, with corroborative evidence, that opiates underwent a gradual shift in function. Opium changed from being a useful product at the local chemist’s, in the old almost medicine-free world, to a highly commercialized commodity during the rise of industrialization, and then to a bone of contention in the struggle for a monopoly on medical prescriptions. At the same time, opium changed in form: laudanum, initially purchased by ordinary working-class people, was superseded by morphine, a substance carefully injected subcutaneously by genteel ladies. And in the early 20th century, this in turn gave way to heroin, which was snorted or injected by the metropolitan proletariat with a fondness for jazz or playing the whore. The latter users ran a big risk of junkification – unless they had the resources and status of great artists, like Charlie Parker. The social and cultural connotations of opiates change not only in line with the organizational structure of the medical profession, but also according to changes in the most conspicuous groups of users who arise in modern breeding grounds where drugs legislation and the economy are the primary determinants.

Courtwright and Acker show that drugs and alcohol policy are essential elements in the political evolution of the functions of the modern state. And hence of the struggle for influence between powerful professional groups that use the state – in this context the medical profession and the law enforcement sector. But neither author deals with the latest trend – the enormous benefits reaped from the prohibition of drugs by the inventors of “good” drugs in the pharmaceutical industry – the most powerful branch of the medical family. [8]

“The Transformation of the Opiate Addict,” which was the final chapter of the first edition of Courtwright’s book, deals with the shift from a medically-based concept of addiction to a view predicated on choice. But whether defined as an iatrogenic or freely chosen form of behaviour, addiction had to be suppressed by prohibition. It is this suppression that constitutes the main thread of Courtwright’s narrative, and he tells the story of the tax legislation that the Federal authorities drafted to achieve it. In a fascinating secondary narrative, Courtwright explains how the institutions that were created to enforce the ban on drugs soon became adept at manipulating data on the different types of addiction: “If the problem of lawmakers and government attorneys before 1919 was to play up the extent of addiction to secure more stringent legislation and rulings, the problem of bureaucrats after 1919 was just the opposite: they needed to show that the stringent laws and rulings had worked!” (p. 116).

Against this background, the story of the different types of addiction is of importance only because these categories provided a structure for the calculations that were made and the way they were manipulated. Harry Anslinger, the famous head of the Bureau of Narcotics in the period between the wars, was to become the prototype of the figure-juggling “drug czar,” a position that still exists in the United States today. [9]

The two new chapters that make the 2001 edition thicker than the original one are less interesting. They contain rather banal accounts of how heroin (and later crack) has remained a problem specific to big cities, and increasingly to big-city ghettoes, and about the increasingly draconian drugs legislation.

It is very striking that after Courtwright has described the successive drug czars from Nixon to Bush Sr, he remarks that modern “drug policy, no longer tied primarily to concerns about heroin, ceased to be tied exclusively to drugs at all, having evolved into a reelection, crime-prevention, revenue-transferring, culture-war omnibus” (p. 179). And here Courtwright demonstrates very clearly that “drugs policy” serves an enormous agenda, in the same way as the Spanish Inquisition, or the recent racial policies of South Africa or Nazi Germany.

I was initially surprised that in spite of the large number of sources that Courtwright introduces and his healthy cynicism vis-à-vis the kings and cardinals of drugs policy, he uses much the same words to discuss drugs as the average employee in the detox business. He is sincerely afraid of drugs, and the stories he tells resemble those told by 19th-century temperance preachers. To him, addiction is a “fact,” in the same way that “bewitchment” was once considered a fact. He does not manage to problematize the aetiology of “drugs” and views of addiction, or to come to grips with the extent to which these concepts are social constructs. He acknowledges the construction of “data” and statistics, but not that of concepts or cultural logic or the way these determine products of society (such as the junkie). In his introduction Courtwright explains that he wants to “present the views of both addicts and non-addicts.” He does so carefully, without subjecting the language they use to meta-analysis. In the latter respect Acker complements his work, so that it is illuminating to read the two studies together.

I see Courtwright’s work as that of a liberal democrat who feels comfortable with the system of the free market but is sometimes uncomfortable with elements of the rhetoric used to discuss it. [10] Courtwright is sometimes harsh with the kings and cardinals of prohibition, but he never questions the legitimacy of their beliefs. Is there anything wrong with that? No, nothing at all. It is still quite normal.

Peter Cohen, January 2005

Translated from the Dutch by Beverley Jackson.

References and select bibliography

Caroline Jean Acker Creating the American Junkie. Addiction Research in the Classic Era of Narcotic Control 2002, Johns Hopkins University Press

Kate Stith and Jose A. Cabranes Fear of Judging: Sentencing Guidelines in the Federal Courts 1998 University of Chicago Press

Jacob Sullum For your own good. The anti-smoking crusade and the tyranny of public health 1998 The Free Press

Norman Zinberg “Addiction and Ego-function” in The Psychoanalytic Study of the Child 30, 1979

The writings of Jay, Cohen, Levine, Reinarman and many other relevant authors can be consulted at http://www.cedro-uva.org

Notes

This review was written in response to a request by the editorial staff of the Academische Boeken Gids in 2003. The editors subsequently declined to publish it, citing its length, its “belligerence,” and the lack of a clear “line.” The version published here is virtually identical to the original version, barring improvements suggested by Erik van Ree, Justus Uitermark, Craig Reinarman and Beverly Jackson.

Gerritsen also discusses taxation as part of the genesis of regulatory regimes that grow up around intoxicants.

An enmeshment that links attributions of causality dating from the Middle Ages to the computer-driven efficiency of modern techniques of investigation and oppression.

The number of prison inmates in Europe averages 100 per 100,000. In the US the figure is over 700 per 100,000 (with some states well over 1,000). These millions of prisoners, hidden away in thousands of prisons and deprived of suffrage and all civil status, will be a crippling heritage for generations of US citizens in 2010 and later (Parenti, Dyer). That the US has created the greatest prison camp in the world has not yet penetrated the political discourse of either the US or Europe.

Like medieval alchemists, NIDA investigators research the form of damage that serves as today’s greatest cultural deterrent, namely brain damage (damage to sexual organs is currently out of fashion). And they are also searching, of course, for the drug that can eliminate “the disease of addiction” in the brain. Most Dutch addiction experts follow this fashion, which has been hyped with NIDA dollars.

The confusion that can make people into wrecks if they are fired or find themselves for some other reason unemployed and lacking a structured working day is not seen (nor should it be, of course) as an effect of frustrated “addiction to work.” And that most people rush off to find another job in a desperate bid to have something to do and to preserve their social status is not seen as a “relapse into addiction to work.”

Few defy the dogma, and those who do suffer a dire fate. Thus Frenk and Dar’s superb Critique of Nicotine Addiction (2000) was decried as “prompted by the tobacco industry” (that modern devil) and as wholly at odds with prevailing views. And so it is!

Big pharmaceutical companies spend massive sums of money on the “Just say no” and “This is your brain on drugs” campaigns in the US. For them, the landscape of “bad drugs” is the lucrative background against which they can construct the myth of their own “‘irrefutable quality.” Physicians, especially psychiatrists, have developed a strong attachment to pharmaceutical products and the PR surrounding them, so they profit from this mythology. (This is not to say that I deny that new products may have or acquire some value!)

The former drug czar McCaffrey famously claimed that its drugs policy had made the Netherlands into the most murderous nation in the world, citing the (fictitious) figure of 8 murders for every 100,000 people each year. Today’s drugs czars call the Netherlands the “Colombia” of ecstasy, egged on by Dutch accomplices, informers and public prosecutors whose salaries depend on investigations of the ecstasy trade (or American provocateurs with diplomatic immunity derived from their attachment to the US Embassy).

It should be said that Hans van Mierlo, the model liberal democrat, was the only Dutch politician ever to display the intellectual and political courage to criticize the prohibitionist dogma in the big assembly rooms of the United Nations.